USVI ENROLLMENT APPLICATION

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NOTE: USVI GOVERNMENT EMPLOYEES, CONTACT GLOBAL MEDEVAC DIRECT:
340-776-6822 • #2 Tenth Street, St. Thomas, VI 00802

* = Required fields

Primary Member Information:

Note: Preexisting conditions are covered after 90-days

Member's Spouse Information:

Note: Preexisting conditions are covered after 90-days

Dependent's Information:

Note: Preexisting conditions are covered after 90-days

Second Dependent's Information:

Note: Preexisting conditions are covered after 90-days

Home Benefits Address:

Mailing Address (IF DIFFERENT FROM HOME BENEFITS ADDRESS):

Agent Information:

Preferred Payment Method: *

Note: a Global Medevac agent will reach out to you to process your payment

REFERRAL INFORMATION:

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